Youth and Young Adult Suicide Report

YouthOklahoma and Young Adult 2020Suicide Report Contents Page # 25 24 19 4 3 23 22 21 20 19 14 11 9

Oklahoma Violent Death Reporting System

Attempted Suicide Inpatient Hospital Discharge Data Executive Summary

Leading Suicide Methods/Means Made aPlan to Attempt Suicide

Leading Circumstances Signs ofDepression

10 6 5 18 13 12 Rate 4 15 Suicide Attempt that Resulted inInjury 8 17 16 Attempted Suicide 7

Considered Attempting Suicide Youth Risk Behavior Survey Resources Methodology 9

Demographics Race Gender/Race/Ethnicity Overview Gender

Age Gender Age group Gender Substance use Race/ethnicity Race Gender EXECUTIVE SUMMARY On average, two Oklahomans ages 10-24 die by suicide every week. Suicide is the second leading cause of death for this age group and rates have been increasing over the past 10 years.1 Data from the Oklahoma Violent Death Reporting System (OKVDRS) show that in 2016, more Oklahoma youth ages 10-24 died by suicide than from cancer, heart disease, HIV, chronic lower respiratory disease, complicated pregnancies, congenital anomalies, influenza and pneumonia combined.

Over the past ten years, suicide rates among youth in Oklahoma have been above those for the United States. Oklahoma ranked 10th highest (worst) in the nation for youth suicide death rates among all states from 2012-2016. For the latest five years in which data are available, there were 533 suicide deaths (2012- 2016) and 3,040 suicide attempts (2010-2014) that occurred among Oklahomans ages 10-24. Combined, these figures are equal to 38 division I college football teams.

The majority of youth suicide deaths in Oklahoma were among males. However, the Oklahoma youth male suicide rate increased 102 percent since 2007, while the youth female suicide rate increased at 112 percent in the same time frame. Among races, both genders of American Indian/Alaskan Native, non-Hispanics 10-24 years of age had the highest rates of suicide.

Current mental health problems and intimate partner problems are the two leading circumstances associated with youth suicide in Oklahoma. Data from the Youth Risk Behavior Survey (YRBS) showed that one in four students reported they felt sad or hopeless almost every day for two or more weeks in a row, so much so they stopped doing some usual activities. Gender disparities existed, with females significantly more likely to report serious thoughts of suicide and recent suicide attempts.

Firearms, hanging/strangulation, and poisoning were among the leading methods of suicide among youth. Other methods included sharp/blunt instruments, fall/jump, motor vehicles/transportation, fire and drown- ing. Methods varied by age and gender.

According to the Centers for Disease Control and Prevention, there is no single reason an individual consid- ers, attempts, or completes suicide. Although risk factors are associated with suicide rather than the direct cause, it is important to know the risk factors and warning signs of suicide. Similarly, parents and profes- sionals should know there are protective factors or ways in which to prevent youth suicide. If you suspect someone you know is suicidal, there are resources that can help you assist them.

3 OKLAHOMA VIOLENT DEATH REPORTING SYSTEM Suicide Rates for Youth and Young Adults Ages 10-24 by Year of Death Suicide rates in Oklahoma and the U.S. have been trending upward over the past 10 years. The Oklahoma youth suicide rate increased 103% since 2007, compared to a 42% increase in the youth suicide rate nationally for the same time period. The Oklahoma youth male suicide rate increased 101% since 2007, and the youth female suicide rate increased 111% in the same time frame. The Oklahoma youth male suicide rate is over 4 times that of the rate of suicide for 10-24 year old Oklahoma resident females.

SUICIDE RATES FOR YOUTH AND YOUNG ADULTS AGES 10-24: U.S. and Oklahoma 2007-2016

30 25 20 15 10 5 Number of deaths per 100,000 population Number of deaths 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Oklahoma Youth OK Youth Males OK Youth Females

Oklahoma All Ages U.S. Youth

Data Source, US Rate: Web-based Injury Statistics Query and Reporting System (WISQARS)

4 DEMOGRAPHICS From 2012 to 2016, there were 533 suicides among Oklahoma resident youth ages 10-24. This is an average of 107 deaths per year. Among this age group, the average age was 19.6, and 80% of suicides were male.

2012-2016 OK Residents Age 10-24

N 533

Rate Per 100,000 13.2

Average Number of Suicides Per Year 107

Average Age 19.6

80% Male Gender 20% Female

Data Source: Oklahoma Violent Death Reporting System

Data Source, US Rate: Web-based Injury Statistics Query and Reporting System (WISQARS)

5 GENDER The suicide rate among male and female youth increased with age. The rate among males increased seven- fold, while the rate among females increased by a multiple of four.

AGE AND GENDER SPECIFIC RATES OF SUICIDE: OKLAHOMA 2012-2016

35 33.1 30 25 21.1 20 23.0 15 14.4

10 8.2 4.8 5 3.5 5.3 2.2

Number of deaths per 100,000 population Number of deaths 0 10-14 15-19 20-24

Male Female All Youth

Data Source: Oklahoma Violent Death Reporting System

6 RACE/ETHNICITY AND AGE American Indian/Alaskan Native, non-Hispanic youth had the highest rate of suicide among all age groups, followed by white, non-Hispanic youth.

AGE GROUP, RACE, AND ETHNICITY SPECIFIC RATES OF SUICIDE FOR YOUTH AND YOUNG ADULTS AGES 10-24: OKLAHOMA 2012-2016

30 29.5 25

20.8 20.6 20 18.2 16.6 15.5 15 10.6 10

5.4 4.4 5 3.8 3.7

Number of deaths per 100,000 population Number of deaths 1.0 0 Data Source: Oklahoma Violent Death Reporting System 10-14 15-19 20-24

White, NH American Indian/Alaskan Native, NH Black, NH Hispanic

Data Source: Oklahoma Violent Death Reporting System NH=Non-Hispanic

7 GENDER AND RACE/ETHNICITY

Males consistently had higher rates of suicide than females among all race and ethnic groups. American Indian/Alaskan Native, non-Hispanic males ages 10-24 had the highest suicide rate among all gender, race, and ethnic groups, with a rate 39% higher than white, non-Hispanic males, who had the second highest rate among all groups. American Indian/Alaskan Native, non-Hispanics and white, non-Hispanics had the highest rates among females. Black, non-Hispanic females experienced the lowest suicide rate among all gender, race, and ethnic groups.

GENDER, RACE, AND ETHNICITY SPECIFIC RATES OF SUICIDE FOR YOUTH AND YOUNG ADULTS AGES 10-24: OKLAHOMA 2012-2016

29.9 30 Male

Female 25 21.5 20

15 13.8 14.2

10 6.3 5.4 4.0

Number of deaths per 100,000 population Number of deaths 5 2.9 0 White, NH American Indian/ Alaskan Black, NH Hispanic Native, NH

Data Source: Oklahoma Violent Death Reporting System NH=Non-Hispanic

8 SUICIDE ATTEMPT INPATIENT HOSPITAL DISCHARGE DATA

Females experienced higher rates of inpatient hospital discharges due to attempted suicide than males. The rate of female suicide attempt discharges steadily increased over that of male discharges from 41% higher in 2010 to over twice the number of male discharges in 2014.

SUICIDE ATTEMPT* INPATIENT HOSPITAL DISCHARGES FOR YOUTH AND YOUNG ADULTS AGES 10-24 BY YEAR OF DISCHARGE AND GENDER: OKLAHOMA 2010-2014

120 105.8 108.5 98.7

100 85.4 76.5 80 85.8 80.4 72.4 76.2 60 64.9 66.8 60.1 53.9 54.9 53.8 40 20

Rate of discharges per 100,000 population of discharges Rate 0 2010 2011 2012 2013** 2014**

Male Female All

Data Source: Oklahoma Hospital Discharge Database Compiled by: OSDH Injury Prevention Service *First-listed valid external cause of injury code in E950-E959 **Due to reporting issues for external cause of injury codes, the number of discharges may be underestimated for 2013 and 2014.

9 SUICIDE ATTEMPT* INPATIENT HOSPITAL DISCHARGES FOR YOUTH AND YOUNG ADULTS AGES 10-24 BY YEAR OF DISCHARGE AND RACE: OKLAHOMA 2010-2014

120 100 80 60 40 20

Rate of Discharges per 100,000 population of Discharges Rate 0 2010 2011 2012 2013** 2014**

American Indian/Alaskan Native, NH Black, NH White, NH

Hispanic All

10 LEADING SUICIDE METHODS

Firearms were utilized for suicide by over half of the youth; the majority of those used a handgun. Nearly two out of five suicides were from hanging/strangulation.

Suicide Methods/Means among 10-24 Year Olds: Oklahoma 2012-2016 Firearms 55% Handgun 72% Shotgun 15% Rifle 11%

Hanging/Strangulation/Suffocation 35%

Poisoning 5%

Fall 2%

Sharp Instrument 1%

Other Blunt Instrument Fire/Burns 3% Motor Vehicle Other Transport Vehicles

Data Source: Oklahoma Violent Death Reporting System

Firearms were the predominant means of suicide among all races and ethnicities except for American Indian/ Alaskan Native, non-Hispanic youth, who used hanging/strangulation equally as much as firearms as a means of death.

Suicide Methods by Race: Oklahoma 2012-2016 Method/Means American Indian/ Black, NH White, NH Hispanic Alaskan Native, NH Firearms 47% 58% 57% 51%

Hanging/ Strangulation/ 47% 33% 33% 35% Suffocation

Other 6% 8% 10% 14%

Data Source: Oklahoma Violent Death Reporting System NH=non-Hispanic 11 METHODS OF SUICIDE BY GENDER FOR YOUTH AND YOUNG ADULTS AGES 10-24

Males predominantly used firearms as a means of suicide followed by hanging/strangulation, whereas females ages 10-24 used hanging/strangulation more than firearms.

METHODS OF SUICIDE FOR MALES AGES 10-24: OKLAHOMA 2012-2016

Other Poisoning 5% 4%

Hanging/ Strangulation Firearms 36% 59%

METHODS OF SUICIDE FOR FEMALES AGES 10-24: OKLAHOMA 2012-2016

Other 3% Poisoning 9%

Firearms 40% Hanging/ Strangulation 45% 12 Data Source: Oklahoma Violent Death Reporting System METHODS BY AGE GROUP Firearms were the predominant method of suicide for youth ages 10-24. As youth age, firearm usage increases, while hanging/strangulation and poison both steadily decreases as a means of death.

METHOD OF SUICIDE AMONG PERSONS 10-24 YEARS OF AGE BY AGE GROUP, OKLAHOMA, 2012-2016

30 Percent

0 10-14 15-19 20-24

Firearms Hanging Poison Other

Data Source: Oklahoma Violent Death Reporting System

13 LEADING CIRCUMSTANCES

Intimate partner problems are the leading circumstance associated with suicide for youth ages 10-24, followed by one or more diagnosed/treated mental health issues and depressed mood. Depressed mood in these data represents a general mood or attitude noted in the record by friends and family upon interview after the death. One or more diagnosed/treated mental health problems represent a medical diagnosis by a medical or mental health practitioner. One in ten (12%) had a history of ever receiving mental health treatment and 8% were receiving mental health treatment at the time of death.

Leading Circumstances/Stressors Associated with Suicide for Youth Ages 10-24 Years, Oklahoma Residents, 2012-2016 Intimate Partner Problem 39%

One or more diagnosed/treated Mental 36% Health Problems Of those identified as having a mental health problem Depression 69% Bipolar Disorder 8% Schizophrenia 4% Attention Deficit/Hyperactivity Disorder 4% Post-Traumatic Stress Disorder 1% Anxiety Disorder 2%

Depressed Mood 29%

Argument 23%

Substance Abuse Problem 20%

Alcohol Problem 10%

Recent Criminal Legal Problem 9%

Job Problem 7%

Data Source: Oklahoma Violent Death Reporting System Victims may be coded for one or more circumstance.

14 When looking at circumstances associated with suicide in males and females, the leading circumstances identified for males were intimate partner problems, a current diagnosed/treated mental health issue, and/ or a current depressed mood. Alternatively, the leading circumstances for females were a diagnosed/treated mental health issue, followed by intimate partner problems, and/or an argument.

Leading Circumstances by Gender for 10-24 Year Olds, Oklahoma Residents, 2012-2016 Rank Males Females Intimate Partner Problems Current Mental Health Problems 1 36% 53%

Current Mental Health Problems Intimate Partner Problems 2 32% 50%

Current Depressed Mood Argument 3 30% 30%

Argument Current Depressed Mood 4 21% 26% Substance Abuse Problem Substance Abuse Problem 5 19% 24% Data Source: Oklahoma Violent Death Reporting System Victims may be coded for one or more circumstance.

15 Intimate partner problems were the leading circumstance for all race and ethnic groups except for white, non-Hispanic youth, whose leading circumstance was a diagnosed mental health problem.

Leading Circumstances by Race/Ethnicity for 10-24 Year Olds, Oklahoma Residents, 2012-2016

Rank American Indian/ White, NH Black, NH Hispanic Alaskan Native, NH

Intimate Partner Current Mental Intimate Partner Intimate Partner 1 Problems Health Problems Problems Problems 39% 42% 43% 47%

Current Depressed Intimate Partner Current Mental Current Depressed 2 Mood Problems Health Problems Mood 28% 37% 31% 29%

Substance Abuse Current Depressed Current Depressed Argument 3 Problem Mood Mood 25% 27% 30% 31%

Current Mental Argument Recent Criminal Current Mental 4 Health Problems 24% Legal Problem Health Problems 26% 23% 18%

Argument Substance Abuse Argument Substance Abuse 5 18% Problem 20% Problem 20% 18%

Data Source: Oklahoma Violent Death Reporting System Victims may be coded for one or more circumstance. NH=Non-Hispanic

16 When looking at circumstances by age group, differences stand out for the 10-14 year old age group. The leading circumstances for 10-14 year olds were current diagnosed mental health problem, followed by current depressed mood. Fifteen to 24 year olds had similar circumstance rankings with intimate partner problems being the leading circumstance for both groups.

Leading Circumstances by Age Group for 10-24 Year Olds, Oklahoma Residents, 2012-2016

Rank 10-14 Years 15-19 Years 20-24 Years

Current Mental Health Intimate Partner Intimate Partner 1 Problems Problems Problems 31% 37% 44%

Current Depressed Mood Current Depressed Mood Current Mental Health 2 22% 36% Problems 41%

Current Mental Health Current Depressed Argument 3 Problems Mood 18% 29% 27%

School Problems Argument Substance Abuse 4 18% 21% Problem 26%

Intimate Partner Substance Abuse Problem Argument 5 Problems 16% 25% 18%

Data Source: Oklahoma Violent Death Reporting System Victims may be coded for one or more circumstance.

Slightly above one-third of youth ages 10-24 who died by suicide in Oklahoma left a suicide note. Almost one-third had a history of suicidal thoughts. Just over one-fifth had disclosed suicidal intent or plans prior to their death and one-fifth had a history of attempting suicide.

Suicide Circumstances for Youth Age 10-24 Years, Oklahoma Residents, 2012-2016 Suicide Note 34%

History of Suicidal Thoughts 31%

Disclosed Suicidal Intent 23%

History of Suicide Attempt 21%

Data Source: Oklahoma Violent Death Reporting System Victims may be coded for one or more circumstance. 17 The majority of youth were tested for alcohol after their death. As youth age, alcohol was more likely to be present at the time of death with 40% of those tested testing positive in the 20-24 age group. Roughly half of all youth were tested for substances other than alcohol at the time of their death. Overall, five percent of the youth tested for other substances tested positive.

Substance Use Associated with Youth Suicide, Ages 10-24, Oklahoma Residents, 2012-2016

Overall 10-14 15-19 20-24

Alcohol tested 96% 100% 94% 97%

Of those tested, 28% 5% 17% 40% positive for alcohol

Substances other 44% 44% 47% 41% than alcohol tested

Of those tested, positive for substance 5% 5% 4% 5% other than alcohol

Data Source: Oklahoma Violent Death Reporting System

18 YOUTH RISK BEHAVIOR SURVEY Signs of Depression The percentage of students who felt sad or hopeless during the 12 months before the survey, has seen no statistically significant change over the last 14 years at 27.1% in 2003 to 31.8% in 2017.

PERCENTAGE OF STUDENTS WHO FELT SAD OR HOPELESS ALMOST EVERY DAY FOR 2 OR MORE WEEKS IN A ROW SO THAT THEY STOPPED DOING SOME USUAL ACTIVITIES DURING THE TWELVE MONTHS BEFORE THE SURVEY: OKLAHOMA YRBS 2003-2017

35 35 31.8 27.9 28.2 28.6 28.9 30 27.3 25 27.1 25.7 20

Percent 15 10 5 0 2003 2005 2007 2009 2011 2013 2015 2017 Year In 2017, females were significantly more likely than males to have felt sad or hopeless during the 12 months before the survey at 43.9% and 20.1%, respectively.

50 43.9

40 31.8 30

20.1

Percent 20

0 Total Female Male

Gender No differences were observed by grade or race/ethnicity. 19 Considered Attempting Suicide The percentage of students who seriously considered attempting suicide during the 12 months before the survey has seen no statistically significant change over the last 14 years with 15.4% in 2003 and 19.1% in 2017.

PERCENTAGE OF STUDENTS WHO SERIOUSLY CONSIDERED ATTEMPTING SUICIDE DURING THE 12 MONTHS BEFORE THE SURVEY: OKLAHOMA YRBS 2003-2017

20 19.1 15.7 15.4 15.4 14.9 15 15.1 13.9 14.3 10 Percent

0 2003 2005 2007 2009 2011 2013 2015 2017

Year

In 2017, differences were observed by gender as females were significantly more likely than males to have seriously considered attempting suicide during the 12 months before the survey at 27.8% and 10.9%, respectively.

PERCENTAGE OF STUDENTS WHO SERIOUSLY CONSIDERED ATTEMPTING SUICIDE DURING THE 12 MONTHS BEFORE THE SURVEY, BY GENDER: OKLAHOMA YRBS 2017

30 27.8

19.1 20

15 10.9 Percent 10

0 Total Female Male

Gender No differences were observed by grade or race/ethnicity. 20 Made a Plan to Attempt Suicide The percentage of students who made a plan about how they would attempt suicide during the 12 months before the survey has seen no statistically significant change over the last 14 years with 13.3% in 2003 and 13.4% in 2017.

PERCENTAGE OF STUDENTS WHO MADE A PLAN ABOUT HOW THEY WOULD ATTEMPT SUICIDE DURING THE 12 MONTHS BEFORE THE SURVEY, BY YEAR: OKLAHOMA YRBS 2003-2017

14.6 15 13.3 13.4 12.4 11.7 10 10.9 10.9 10.7 Percent 5

0 2003 2005 2007 2009 2011 2013 2015 2017

Year Differences were observed by gender as females were significantly more likely than males to have made a plan about how they would attempt suicide during the 12 months before the survey at 18.6% and 8.6%, respectively.

PERCENTAGE OF STUDENTS WHO MADE A PLAN ABOUT HOW THEY WOULD ATTEMPT SUICIDE DURING THE 12 MONTHS BEFORE THE SURVEY, BY GENDER: OKLAHOMA YRBS 2017

20 18.6

15 13.4

10 8.6 Percent

0 Total Female Male Gender 21 No differences were observed by grade or race/ethnicity. Attempted Suicide The percentage of students who attempted suicide one or more times during the 12 months before the survey has seen no statistically significant change over the last 14 years from 7.0% in 2003 to 11.2% in 2017.

PERCENTAGE OF STUDENTS WHO ATTEMPTED SUICIDE ONE OR MORE TIMES DURING THE 12 MONTHS BEFORE THE SURVEY, BY YEAR: OKLAHOMA YRBS 2003-2017

10 11.2 7.9 8 7.0 6.8 7.4 6 7.0 5.9 6.3 Percent 4

0 2003 2005 2007 2009 2011 2013 2015 2017

Year

Differences were observed by gender as females were significantly more likely than males to have attempted suicide one or more times during the 12 months before the survey at 15.7% and 6.2%, respectively.

PERCENTAGE OF STUDENTS ATTEMPTED SUICIDE ONE OR MORE TIMES DURING THE 12 MONTHS BEFORE THE SURVEY, BY GENDER: OKLAHOMA YRBS 2017

15.7 15

11.2 10 Percent

6.2 5

0 Total Female Male Gender 22 No differences were observed by grade or race/ethnicity. Suicide Attempt Resulted in Injury The percentage of students who attempted suicide that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse during the 12 months before the survey has seen no statistically significant change over the last 14 years from 2.4% in 2003 to 3.7% in 2017.

PERCENTAGE OF STUDENTS WHO ATTEMPTED SUICIDE THAT RESULTED IN AN INJURY, POISONING, OR OVERDOSE THAT HAD TO BE TREATED BY A DOCTOR OR NURSE, BY YEAR: OKLAHOMA YRBS 2003-2017

4.0 3.5 3.7 3.0 2.6 2.4 2.5 2.0 2.1 2.0

Percent 1.5 1.8 1.5 1.0 1.1 0.5 0.0 2003 2005 2007 2009 2011 2013 2015 2017

Year

No differences were observed by gender, grade, or race/ethnicity for the percentage of students who attempted suicide that resulted in an injury that had to be treated by a doctor or nurse.

23 DATA SOURCES OKVDRS Methodology Data were obtained from the National Violent Death Reporting System (NVDRS), a population-based active surveillance system that collects data on violent deaths from 40 participating states and two territories. Each state uses the same case definitions and coding manual and en- ters data in NVDRS web-based software. Oklahoma’s Violent Death Reporting System (OKVDRS) began collecting data in 2004. Violent deaths include suicides, homicides, and legal interventions; deaths of undetermined manner (intent); and unintentional firearm injury are also included. Data in OKVDRS are collected from medical examiner reports, Vital Statistics (death certificates), and law enforcement reports for all violent deaths that occur in the state. Toxicology testing and re- sults are extracted from medical examiner reports. A trained abstractor assigns the manner of death based on the narratives and the manner of death recorded in the medical examiner’s report, the death certificate, or law enforcement report. A suicide case in the NVDRS is defined as “a death resulting from the intentional use of force against oneself. A preponderance of evidence should indicate the use of force was intentional.”

Limitations The findings of this study are limited to suicides that occurred in Oklahoma of Oklahoma residents ages 10-24 years, and are not generalizable to the population as a whole. The data are abstracted from documents prepared by various officials. A wide range of variation exists in the amount of detail and information documented in the records provided to OKVDRS, likely introducing information bias. The study provides annual incidence, race-, ethnicity-, gender-, and age-specific rates, mechanism of injury, and prevalence of circumstances and other factors documented in the records and coded using NVDRS guidelines. Rates based on small numbers may be unstable. No external comparison group was used for the analysis; only internal group comparisons were conducted. Inpatient hospital discharge data includes data from all non-federal, acute care hospitals licensed by the state. The number of discharges is not necessarily unique patients. Patients could be hospitalized more than once for the same injury or transferred between hospitals. Federal hospitals, such as the Indian Health Service, tribal hospitals, and military hospitals, are not required to report inpatient hospital discharge data; therefore, discharges due to attempted suicide may be underestimated for populations that use these facilities.

YRBS Methodology The statewide, randomized YRBS is conducted biennially on odd-numbered years. The survey covers six categories of health-risk behaviors, the prevalence of obesity, and other health-related topics. Health-risk behaviors included behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases, unhealthy dietary behaviors, and physical inactivity.

Samples were selected using a two-stage sampling design. Schools were first selected for partici- pation based on probability proportional to size (school enrollment in grades 9 through 12). Then classes were selected from each school using systematic equal probability sampling with a random start. The sample was weighted to be representative of public high school students in grades 9 through 12 in Oklahoma based on the demographic distribution of the enrolled student population Five questions were used from the YRBS related to depression and suicide, they were: 1. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? 2. During the past 12 months, did you ever seriously consider attempting suicide? 3. During the past 12 months, did you make a plan about how you would attempt suicide? 4. During the past 12 months, how many times did you actually attempt suicide? 5. If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?

Limitations YRBS data were representative of public school students in grades 9 through 12 in Oklahoma. Ado- lescents who attended private institutions, were home-schooled, or did not attend any school were not represented in this study. There is potential underreporting of risk behaviors by students participating in the YRBS. Despite efforts to conduct the YRBS in such a manner as to preserve confi- dentiality, some students may not report events if they feel their answers will in some way identify them. Furthermore, students read and interpret the questions and form their answers without any external assistance; therefore, students may have different interpretations of the YRBS questions and response options. Statistically significant differences were not observed by grade or race/ethnicity for the depression and suicide questions; however, this is likely due to sample size.

References 1. National Vital Statistics System, National Center for Health Statistics, CDC. Produced by: National Center for Injury Prevention and Control, CDC using WISQARS™

Resources National Suicide Prevention Lifeline https://suicidepreventionlifeline.org/ 1-800-273-TALK (8255). American Association of Suicidology http://www.suicidology.org/ American Foundation for Suicide Prevention https://afsp.org/ Suicide Prevention Resource Center http://www.sprc.org/

State/Local Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) https://www.ok.gov/odmhsas/ or the Reachout Hotline at 1-800-522-9054 National Alliance on Mental Illness (NAMI) https://namioklahoma.org/ or the Helpline at 1-800-583-1264 Heartline http://www.heartlineoklahoma.org/ Mental Health Association of Oklahoma http://mhaok.org/ Oklahoma Suicide Prevention Council https://www.ok.gov/odmhsas/Prevention_Programs/Initia- tives/Youth_Suicide_Prevention_and_Early_Intervention_Initiative/Suicide_Prevention.html Oklahoma State Department of Health https://www.ok.gov/health/ 25 The Oklahoma Violent Death Reporting System is supported by Grant Number 1 NU17CE924931-01-00 from the Centers for Disease Control and Prevention. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention. For more information about the Oklahoma Violent Death Reporting System please call the Injury Prevention Service at 405.271.3430.

Funding for the YRBS is provided in part by the CDC and the Maternal and Child Health Services Title V Block Grant, Maternal and Child Health Bureau, Department of Health and Human Ser- vices. The Oklahoma State Department of Health (OSDH) is an equal opportunity employer. This publication is issued by the Oklahoma State Department of Health. Copies have not been printed but are available for download at http://yrbsdata.health.ok.gov. For more information about the Youth Risk Behavior Survey please call the Maternal and Child Health Service, MCH Assessment at 405.271.6761 or visit http://yrbs.health.ok.gov

26 Oklahoma State Department of Health

This publication was issued by the Oklahoma State Department of Health (OSDH), an equal opportunity employer and provider. A digital file has been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries in compliance with section 3-114 of Title 65 of the Oklahoma Statutes and is available for download at www.documents.ok.gov. | Issued January 2020 | 19235MCHS